RCSLT - Royal College of Speech and Language Therapists

ILJCD: Barriers and Facilitators to Communication Partner Training

• The Royal College of Speech and Language Therapists • Season 6 • Episode 4

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How can we best implement communication partner training with familiar partners of people with aphasia?

In this International Journal of Language and Communication Disorders paper the authors set out to:
(1) determine the perceived and/or observed barriers and facilitators to implementing CPT with familiar partners of adults with aphasia;
(2) to map extracted barriers and facilitators to a common theoretical framework; (3) to synthesise extracted barriers and facilitators; 
and (4) to identify potential implementation strategies to address the most frequently identified barriers and facilitators.
 

Authors Kirstine Shrubsole, Emma Power, Marie-Christine Hallé were awarded the IJLCD 2023 Editors' prize for this paper. 

The paper is:
Communication partner training with familiar partners of people with aphasia: A systematic review and synthesis of barriers and facilitators to implementation

Kirstine Shrubsole, Emma Power, Marie-Christine Hallé


Examples of free, brief online training programs (less than 2 hours)

 

Aphasia Institute Community Hub: Introduction to SCA™ eLearning Module, The Aphasia Institute, Canada

interact-ABI-lity, University of Sydney and University of Technology, Australia

For the article referring to online versus face-to-face here is the IJLCD article reference.

Power, E., Falkenberg, K., Barnes, S., Elbourn, E., Attard, M., & Togher, L. (2020). A pilot randomized controlled trial comparing online versus face-to-face delivery of an aphasia communication partner training program for student healthcare professionals. International journal of language & communication disorders, 55(6), 852–866. https://doi.org/10.1111/1460-6984.12556


First published: 
23 November 2022




Please be aware that the views expressed are those of the guests and not the RCSLT.

Please do take a few moments to respond to our podcast survey: uk.surveymonkey.com/r/LG5HC3R


Transcript Date: 

17 February 2025 

 

HOST:                         JACQUES STRAUSS

KIRSTINE:                  KIRSTINE SHRUBSOLE 

EMMA:                        EMMA POWER 

 


MUSIC PLAYS: 0:00:00-0:00:06

 

HOST:                         0:00:06 Welcome to the RCSLT podcast. My name is Jacques Strauss. This is an IJLCD edition of the podcast in which we talk to authors about papers that have been published in the International Journal of Language and Communication Disorders. And today, we’re talking to Kirstine Shrubsole and Emma Power, whose paper entitled, ‘Communication partner training with familiar partners of people with aphasia: A systematic review and synthesis of barriers and facilitators to implementation’ won the 2023 IJLCD Editors Prize. So, a big congratulations to them on this achievement. 

 

I started by asking Kirstine and Emma to introduce themselves. 

 

KIRSTINE:                  0:00:45 I’m Kirstine Shrubsole. I’m a speech pathologist and a researcher at the Queensland Aphasia Research Centre in Australia, based at the University of Queensland. 

 

EMMA:                        0:00:57 I’m Emma Power. I’m a professor in speech pathology at the University of Technology in Sydney, Australia as well. 

 

HOST:                         0:01:04 What clinical questions were you trying to answer? 

 

KIRSTINE:                  0:01:09 So, the background to this study was that we were fortunate to receive some funding from the Stroke Foundation to conduct a study. And the study that was planned was really looking at improving communication partner training provided by speech pathologists or speech language therapists to family members of people with aphasia. 

 

Part of that funded project required us to develop an implementation strategy to help SLTs improve their practice in this area of communication partner training, or CPT. 

 

To talk a little bit just briefly about CPT, we know that it’s an effective intervention for people with aphasia, so it helps their family members and friends learn strategies to support that conversation and improve their interactions and communication. But we have seen time and time again that, despite the benefits of CPT, it’s not consistently used in practice. 

 

So, this was the background to the larger study and this funded project that we were going to do. And in order to do that, we really needed to understand what were the reasons that CPT wasn’t being provided. What were the key barriers and facilitators for SLTs? That was really what led us to do this study. 

 

We’d seen quite a few things out there and spoken to the different clinicians to know that it was challenging, but we hadn’t seen any real synthesis of all of those challenges together to help us feel confident to be able to develop the strategy that we wanted to develop. 

 

HOST:                         0:02:56 Emma, I understand there’s also a bit of an interesting story about how this research came about. 

 

EMMA:                        0:03:01 Yes. Along with all of this research that we were doing, during COVID, it did disrupt a lot of our research, and it really gave us time to pursue this research in a way that was positive for us, along with our co-authors in Canada. It really was something that wasn’t necessarily fully planned – it was certainly part of what we were doing – but COVID gave us an opportunity to work on this where we didn’t need to be interacting with clients and patients and research participants. And it allowed us to actually deeply look into the literature, which hadn’t been done before, and gather it all together so that speech pathologists didn’t have to read 20 papers, they could read one that we had done the work on, and that work was done through COVID because we could – we didn’t need actual participants. 

 

HOST:                         0:03:57 It’s interesting how COVID affected research. We did a podcast a while ago about research that was made possible because of delays in treatment, so researchers could see if conditions progressed as expected, or what resolved spontaneously, and that type of stuff. 

 

EMMA:                        0:04:14 Well, I think that speech pathologists, speech language pathologists, therapists, are all very creative. I think we hit above our weight level in terms of a lot of the stuff we do and [I think we’re quite 0:04:27] dynamic – we’re able to use opportunities very well. We have to be creative every day, working with clients to find different ways to see it at different angles. I really think that that time allowed people to do that. A lot of people don’t get a lot of time to think in healthcare, and academia, and so I suppose what COVID did is it, in some way, sped some things up, but it slowed some things down and allowed people a bit of a chance to step back, despite it also being a very difficult time for many. 

 

HOST:                         0:05:00 I realise this research was a systematic review, but can you just give us a sense of what the existing literature said. 

 

KIRSTINE:                  0:05:07 In terms of what was already out there, we were aware of quite a few studies. The research itself on communication partner training is quite clear, in saying that we know CPT works and it is an effective intervention, but when we look at this implementation or clinical practice the picture gets more complicated. So yeah, there were quite a few studies that we were aware of that had identified barriers. Things like time constraints for clinicians. Clinicians have said a lack of training opportunities in providing CPT. 

 

And also because of the nature of CPT being quite complex, where you’re training families rather than having that one-to-one with the person or the patient themselves, there brings in that element of complexity from the family side of it. So, sometimes there’s a perception, perhaps, that families aren’t as interested in or are reluctant to come to sessions as well. So, there was quite a lot out there, but it was quite separate. 

 

One of the things in in our field where we’re looking at implementation or improving practice is using some behaviour change theory to really understand why people do what they do and use that to help us inform change. There are a number of frameworks out there, and our idea with this paper was to really use one of these behaviour change frameworks to really synthesise and bring together all the existing literature so it was in a common language, so that we could really use that to help us go forward and develop some strategies that we could use in our research. But also, that clinicians could hopefully pick up the paper and say, okay, I’ve got this barrier; what’s potential strategy that I could use to overcome it in my clinical setting?

 

EMMA:                        0:07:02 I think that it’s very difficult for clinicians to conduct EBP in a very difficult, complex, challenging health and education environment. The point is that having things in lots of different places is in itself a barrier to implementation. The purpose, like I said before, about this is instead of those people having to go and read how many papers, what we really need is that all in one place. You’ve got it in your hand, you’re ready to go, you can quickly scan it and get the information you need because we’ve done the work in the background. I think that the literature is out there, but it’s not always accessible. 

 

And that’s the great thing about doing these kind of reviews, is it does allow for that. But also in the future, if someone said 10 years later, let’s repeat it, then they can do an update very easily based on the template we’ve already done. 

 

HOST:                         0:07:58 Can you tell us a bit more about how the research was undertaken?

 

KIRSTINE:                  0:08:02 There were three researchers in our team, so it’s myself and Emma and a Canadian researcher, Dr Marie-Christine Hallé, and we worked together to conduct this systematic review. We searched databases, we had some criteria that we were looking at, and then we selected the articles from the databases that came out and it really highlighted the barriers and facilitators from all of those. 

 

We mapped all of the barriers and facilitators that we identified to the theoretical domains framework, which is this behaviour change theory sitting underneath it, and it really helped us to sort of categorise them.

 

And then from then, we worked together, so all of these processes were collaborative. There was quite a rigorous process behind everything, where we were checking each other’s work or doing things independently, and if we didn’t quite agree we’d get the third author to come in and make some decisions. 

 

And after we’d gone through this process of selecting our articles and extracting and then mapping it to this framework, we then proposed some of those strategies that we thought might be useful. 

 

EMMA:                        0:09:16 A lot of the process was joint and involved really getting from a large number of articles. In figure one in our actual study, it shows that we actually got started with 2,115 articles, then we got down to 17 that were actually really about what we wanted to know and eligible. And so, that whole process together is about is this the right article? 

 

The reason we do systematic reviews, and that they’re called systematic, is because we don’t want someone to come up to us later and go, how do you know you’ve got all the stuff? How do you know you’ve got all the research? That’s the point of systematic reviews and this methodology is, it’s rigorous to say with everything that we could do here, we believe that we have all the information that we need and that’s out there. 

 

Mind you, we don’t have multiple languages. We have English and French. So, one limitation is that we didn’t have them all. But the point is that it’s a very rigorous, systematic process with the aim being we didn’t really miss anything. We’ve got all the information we need here. 

 

HOST:                         0:10:22 I’m interested in this term ‘behaviour change’. It comes up a lot in business and, of course, it’s central in healthcare. But it’s not something we’ve discussed much in the podcast. I wonder if you can tell me a bit more about it and what we mean with the term. 

 

EMMA:                        0:10:38 Behaviour change is something that’s with us every day. If you’ve seen anyone that wants to increase their fitness, read more books, actually maybe tidy their room more, all of those things are behaviour change. They take you from a state where you are reflexively doing your tasks to actually change purposely into a new routine. That’s at the core of a lot of us as human beings, as we walk around, but it’s really critical to health. 

 

If we keep doing things the way we’ve always been doing them, that’s a problem. If we know that the research is effective for something like CBT but we have trouble moving to a new routine, then people’s outcomes are not going to be as good. And so, the importance of being able to change is so that we can get better health outcomes. 

 

The problem is, is that change is hard, and so when we talk about behaviour change it can seem flippant. But we have things all over the world trying to help us to do this kind of stuff in all aspects of our lives. When you’re in a complex health system with lots of complexity, uncertainty, different agents moving around everywhere, you’ve got this clinician, the client, the family and the system, then behaviour change becomes quite hard. 

 

And we think one of the things that you could say is, just educate people. There’s some great research around hand-washing and how we can make sure people do that. One of the barriers was that the sinks were in the wrong place. It doesn’t matter how well you educate someone, the sinks are in the wrong place, so they need to be moved. That starts us to get us into the point of behaviour change requires us to work out what’s underneath the reason we’re having trouble changing, and what would be a helper, the barrier, and the facilitator. 

 

In this case, what we’ve really got is we know that CPT is good to do. Behaviour change is about how we can move from one set of behaviours to a new set, or even stop doing other things. We need to know why it’s difficult to change because you can’t just educate people out of that. 

 

HOST:                         0:13:05 Can you tell us, what were the main findings? 

 

KIRSTINE:                  0:13:07 We had 17 studies that met the criteria, and the majority of those were conducted in Canada and the UK, with some conducted in Sweden and the Netherlands and Australia, so just to give you an idea about where we’re seeing these papers that met our eligibility. 

 

There were different types of studies, so some were surveys and some were interviews, and some were intervention studies where they were testing different communication partner training interventions. [Inaudible 0:13:41] brought together we weren’t really restricting the type of study that we included, and it was quite complex, as we thought. 

 

In our paper, we have a number of tables. When we counted up all the barriers that we found, there were 63 different barriers or facilitators that we actually found from these 17 studies. The difficulty was trying to present them in a way that was digestible and related to these theories that we were talking about. 

 

Across the studies, we found that, really, there were these eight key implementation factors. But within each of those factors, there were categories and different reasons that related. There’s much more detail in the paper, of course, but I thought I’d really highlight a couple of key barriers that came out. 

 

The most frequent factor or domain that we found related to the environmental context and resources, and that’s quite common in in healthcare in a lot of literature. We tend to see that people will report limited time as an employee working in health, as well as limited resources. 

 

One of the really interesting things that came out of our study, and it was the most common category within that that environmental context area, was that there’s variable access to the family members in order to provide this communication partner training, which seems obvious for some people, but it might not be for others. In order to provide communication partner training to family, they need to be there, and that’s not always possible. There’s lots of reasons that that family might not be able to attend, but that’s really going to impact whether the clinicians can provide CPT. And that was both a barrier and a facilitator. So, if the family were able to attend, that was a facilitator, and if the family weren’t, that was seen to be a barrier. That starts to plant a seed about, well, what can we do to address that? 

 

Time and resources came up as a as a barrier as well, and clinicians often reported this sense of competing demands, so working in that clinical setting, there’s lots of different priorities that might sometimes take over from providing communication partner training. 

 

In terms of other barriers, some key ones that came out was as well a perception from speech therapists that some families weren’t necessarily willing to be involved, or a sense of reluctance from families, or that maybe families didn’t see the value in it. Again, that provides us with some thoughts around what might that mean? And again, clinicians did say that they [didn’t 0:16:41] have access to formal training opportunities. 

 

So, while there were quite a few barriers, it was helpful to use our framework to categorise them. There were a number of facilitators as well, and I think that that’s important to highlight. 

 

It was really good to see across these studies that there was generally good knowledge about what communication partner training was, and most studies found that clinicians had good support and felt that it was part of their role to be providing CPT. But it was quite a complex area! 

 

EMMA:                        0:17:21 I think… and if your readers are able to get a hold of the paper and look at some of the tables, you sort of get the feel of the voice of the clinicians in it. Time is very common, but when you hear it, ‘I have too little time to describe and explain thoroughly to families’. They’re the kind of things. I think we struggle as well, even in hospital [inaudible 0:17:40] support carers and give them adequate information. You can see the emotion and the fact that these are strongly held ideas of people about how difficult it is. 

 

But it really, I think… it doesn’t surprise me, but it is always endlessly rewarding to see the resilience and the positivity of many speech pathologists, especially when they see that this works. 

 

And I think what surprises me is that for a lot of people, they actually just didn’t think that it might actually be helpful. And I wonder if they had a bad experience with it. Because we don’t tend to do things again when… if it’s hard and it hasn’t worked that well. But it’s not really about us, it’s not personal. And so, I think one of the things that is interesting is that speech pathologists have amazing resilience, they find solutions all the time, and I think that you could see people really trying in the literature, and the words of those people really trying to make this work. And once they got positive reinforcement from clients who said, oh my gosh, this is really helpful, this is working for me, how important that is for speech pathologists to overcome any barriers and push further to do this good work with those families. 

 

HOST:                         0:19:02 It would be interesting to know if all the pressure on the NHS is making these types of interventions more difficult. Australia’s healthcare system is, by all accounts, in a much better state than ours.

 

EMMA:                        0:19:15 I am part of two very large research projects, and one of them is actually happening in the NHS about communication partner training. I would say too also, just something that’s interesting, it does depend on your jurisdiction a bit and the funding models. And I think that if we look to some of the results, some of the… I think, was it the Swedish or… yeah, Sweden. I’m a private practitioner and I have trouble being paid for this, and if you’re in the health system, you might still have trouble being paid for this, but in a different way. And so, I just think that that is probably a universal thing, depending on the nature of the service. 

 

As much as Australia has a very good health system, there are pockets where we can see postcode inequity. It depends on how well you’re funded, it depends on whether or not you’re able to provide services after someone’s been discharged from hospital. That is one of the main concerns that I have is that it sometimes just depends on where you live, and that’s not a good standard for any quality service, and I think that that is a real challenge. 

 

HOST:                         0:20:31 What should clinicians be doing? 

 

KIRSTINE:                  0:20:34 I don’t want to be here saying this is what therapists should do, because I think clinicians are doing the best that they can, but I think – I hope – that what clinicians can do is look at some of these barriers and reflect on their practice, and reflect on their service and try to think about, well, if I’m not doing CPT as well as I think I could, what are some things that I can do in my service. 

 

One of the things that clinicians might consider is really how to have it be part of usual care? How can we improve CPT being something that’s done consistently and offered consistently to families? Families might choose not to take it up, but it’s a conversation and I think that it’s possible, as some of those quotes from the paper highlight, it’s possible that clinicians aren’t having the time to really sit down with families and explain what it is. 

 

I think that’s one of the key things is really to have those conversations with family about communication partner training, explaining to them that it’s an effective part of aphasia therapy, so that they know what it is, they know what to expect. And then they might decide at some point, if it’s not possible to do it in early on in the stroke journey, in the stroke recovery journey, at least they’ve heard of it. But there’s also some potential for clinicians to give examples of what it might look like and integrate it within their sessions without it having to blow out and be something that’s really outside of the realm of what they can offer within the service that they have. Yeah, I think that that’s something for clinicians to think about. 

 

And really just working together as well. I think knowing that clinicians are probably all finding it challenging, so working with each other and reaching out to be able to attend training, perhaps get some mentorship from clinicians who are doing it well, and also reach out to universities who might be able to support them as well.

 

EMMA:                        0:22:54 Reaching out is a really, really important thing. As part of my role, one of the most enjoyable things is engaging with clinicians to make their lives better in order to increase outcomes for patients. I do a lot of workshops on implementation with CPT, and have done so recently in Australia in one of our cities, Dubbo. And some of those clinicians, with that support, they [inaudible 0:23:20] a lot actually, but they know that I’m there and I’ve given them what I can have run off and done amazing things where they’d actually engaged with a project looking at increasing dosage of physical and occupational therapy and speech therapy in the inpatient setting, which can be enhanced by good communication so that the people with aphasia, with communication disabilities, are going to get more opportunity to get better practice. 

 

And so, they’ve actually done a project where they’ve worked with physiotherapists and occupational therapists, so that they can know what they need. Then they’ve actually together come up with the programme. We’ve got other examples in the same health service of people doing similar kinds of things. 

 

I think sometimes reaching out and having someone behind you and then going with that information, and then trying to find champions in your other professions who want… and we have to offer something. We can’t ask people to do things if we’re not offering. Offering the opportunity to have a more efficient session, a more successful and respectful session, and one where you’re more able to actually achieve outcomes. I think that that’s part of something that’s important by engaging and reaching out, you can facilitate a lot on top of that. 

 

HOST:                         0:24:46 To what extent can we lessen the burden on therapists by making resources available like training videos or podcasts and that type of stuff? 

 

KIRSTINE:                  0:24:56 That’s a great question, actually, because one of the barriers, as we said, was that family members might not be able to attend, particularly during the business hours and then they’re working. And then COVID as well, there were visitor restrictions and things like that. I think that that was something in a recent study that we’ve just completed that we did highlight to clinicians that it would be good to reach out and be able to send resources. 

 

And I guess the difficulty might be that you don’t know what they’re taking from that. However, I think that this is definitely where we need to be going. And I know that there are digital communication partner training modules that have been developed. I think that there probably needs to be more awareness and potentially more access to those because I think that that is so important. 

 

I know that hospitals do run face-to-face sessions, group sessions, in some circumstances, but they’re quite resource intensive. Having a different option for people who can’t come in for people, I totally agree, I think that that’s where we’re headed. 

 

HOST:                         0:26:08 There is a link in the show notes to some other research that Emma and Kirstine did about the efficacy of providing digital resources versus in person training. 

 

Do you have any final thoughts or take-home messages for the listeners? 

 

KIRSTINE:                  0:26:27 I would say if you’re finding it challenging to provide CPT, just knowing that you’re not alone, and that’s very common. There’s lots of other clinicians who are interested and also working towards improving their practice. Hopefully, you can have a look at some of the strategies that we highlighted in our paper, and think about how you might work to bring them on board and improve your practice for yourself. 

 

Just one example. If, for example, you’re working in that early rehabilitation setting, making sure that you provide all new families with aphasia with that information about CPT and what it is, and really highlighting the benefits so that they know what it is and they know it’s an option, and that it’s a really good option. That can also hopefully increase their motivation to participate and actually attend the sessions when you’re able to offer them. So, really encouraging families to come to sessions, and if they aren’t able to come, thinking about what could you send them so that they have some information, so that everybody with aphasia, their family member has some information on how to communicate with them. Because what we hear is down the track, sometimes months, sometimes years later, is family saying, I wish I knew back then what I know now. And no one ever told me, and no one ever trained me. And so, I think we just always need to keep in the back of our mind the family voice and what the experience of people with aphasia and their families. 

 

Sometimes, as clinicians in hospitals, we might never see that, so just thinking, if I offer this now they might say no, but maybe they won’t. Maybe I can send them something and it’s really going to help them communicate, and maybe they can access some further services. So, I think just offering it early, offering it consistently, that would be my take-home message. 

 

EMMA:                        0:28:20 I think also that sometimes the best person to support a stroke survivor’s family member in thinking about CPT is another stroke survivor’s family member who has done CPT. What we talk about implementation is, well, who’s the most credible educator and influencer. I’ve been working sometimes with speech pathologists, and it’s part of what we’ve actually listed in this paper, is getting videos of stroke survivors, partners, and stroke survivors themselves saying, what it’s like to do CPT, how it’s helped them, and use that to actually influence people to have more of an empathetic understanding of what this could be and what it could be as a benefit to me, despite all the trauma, the difficulty, the time difficulty, it’s worth it because of this. 

 

I think that that’s one of my key take-aways, is we need to work together, and that that’s one of the implementation strategies to persuade people to do something that’s hard is to help by having peers tell them how it is. 

 

HOST:                         0:29:31 A very big thank you to Kirstine and Emma for their time. As always, please see the show notes for links to the paper and other material of interest. If you have any thoughts on providing CPT, on collaboration with other allied health professionals, or resources that are being used, please do get in touch and let us know what you’re doing. 

 

Until next time, keep well.

 

MUSIC PLAYS: 0:29:54